MSK Flashcards
Difference between strain and sprain
Sprain = injury to ligament
Strain = injury to tendon
Feature of 3rd degree strain
muscle tears all the way through
‘pop’ sensation – muscle rips into 2 or shears away from tendon
Symptoms of ankle sprain/strain
- Swelling
- bruising
- pain after injury
Most common ankle sprain
inversion ankle sprain = where excessive plantar flexion and supination cause the anterior talofibular ligament (ATF) to be affected.
What imaging is used to identify fractures/dislocation?
x-ray
When is x-ray indicated in ankle fractures?
Clinical exam with Ottawa rules:
X-rays are only necessary if there is pain in the malleolar zone and:
- Inability to weight bear for 4 steps
- Tenderness over the distal tibia
- Bone tenderness over the distal fibula
What is fibromyalgia?
Widespread pain throughout the body with tender points at specific anatomical sites.
Features of fibromyalgia
- Chronic, long term, widespread pain >3months
- -> Pain in back and neck, or “all over”
- -> Worsened in cold weather, stress, activity, and associated morning stiffness - Additional symptoms: fatigue, trouble sleeping, memory difficulties, mood difficulties
- O/E: diffuse tenderness, with 11/18 tender trigger points (used less and less in practice)
Diagnosis is clinical
Define polymyalgia rheumatica
Inflammatory condition causing pain in the hip and shoulder girdles.
Pain NOT weakness
–> in older people characterised by muscle stiffness and raised inflammatory markers.
Features of polymyalgia rheumatica
- usually rapid onset (e.g. < 1
- aching, morning stiffness in proximal limb muscles
- also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
Investigations for polymyalgia rheumatica
Raised inflammatory markers : ESR > 40 mm/hr, elevated CRP
What symptom is not associated with polymyalgia rheumatica?
weakness
What is gout?
- Form of inflammatory arthritis
- Uric acid crystal deposition in joint causing episodic acute swelling/pain in joint(s).
- monosodium urate monohydrate in the synovium
Features of gout
- Painful swollen joint - can mimic septic arthritis
- Acute
- Sudden onset of pain lasting 1-2wks
- Spontaneous but may have trigger
- Big toe, ankle joint, finger joints, elbow
- Skin is red and shiny, swollen and hot, tender
- VERY PAINFUL – SHEET CANNOT TOUCH TOE
- May have associated skin findings, Tophi (stone)
- Intermittent attacks of acute joint pain, very tender, red - Typically first presentation is the 1st MTP - PODAGRA
Gold standard for gout
Joint aspiration and crystal analysis.
Negatively birefringent crystals
Other investigations for gout
- Serum uric acid levels- may be raised
- ***PEARL: Patients may have chronic raised uric acid but during an acute attack, uric concentrations may fall and uric acid during a flare is not a good diagnostic test
- Leucocytosis, raised ESR and CRP during acute attack
What are the radiological features for gout?
- joint effusion is an early sign
- well-defined ‘punched-out’ erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
- relative preservation of joint space until late disease
- eccentric erosions
- no periarticular osteopenia (in contrast to rheumatoid arthritis)
- soft tissue tophi may be seen
What is pseudogout?
Form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium
Features of pseudogout
- knee, wrist and shoulders most commonly affected
- joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
- Red, hot swollen, episodic attacks.
Investigation for pseudogout
- x-ray: chondrocalcinosis
- -> in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
What is rheumatoid arthritis?
Systemic, Inflammatory Joint disorder
What is osteoarthritis?
AKA “degenerative joint disorder” as it is a degenerative form of arthritis that gets worse with age and is associated with overuse.
Clinical features of osteoarthritis
- All joints can be affected: mostly knees, hip, hands, lumbar and cervical spine
- Worse with more activity and use
- Joint pain and disability
- Affects one or more weight bearing joints - Decreased ROM + function, joint crepitus, deformity, effusion, muscle weakness, wasting
- Joint pain without or without stiffness. Pain»_space;>Stiffness
- Symptoms increase with activity; diminish with rest
- Usually little or no swelling or redness of adjacent tissues
- Heberden’s nodes (DIP) - (osteophytes on distal interphalangeal joints)
- Bouchard’s nodes (PIP) - (osteophytes on proximal Interphalangeal joints)
Joints affected by Osteoarthritis vs Rheumatoid arthritis
Osteoarthritis = Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints
Rheumatoid arthritis = MCP, PIP joints
How is osteoarthritis diagnosed?
1st line = x-ray:
- Loss of joint space/joint space narrowing (because of cartilage loss)
- subchondral sclerosis (cysts)
- osteophytes (new bony formation)
Clinical features of Rheumatoid arthritis
- Predominantly peripheral joints (hands,feet)
- Ulnar deviation
- Swan neck deformity (hyper extended PIP, flexed DIP)
- Boutonniere (hyper extended of DIP, flexed PIP)
- Z thumb deformity (hyperextension of interphalangeal joint) - Polyarthritis (multiple joints)
- Symmetrical joint pain, effusions, soft tissue swelling
- Functional loss (especially in the hands)
- Progresses to joint destruction and deformity
- Tendons may rupture; bone alignment affected
- Systemic signs of inflammation (fever, malaise, anorexia)
- Early morning stiffness that doesn’t get better/worse with activity/time
What test would you carry out in rheumatoid arthritis?
Positive squeeze test
- discomfort on squeezing across the metacarpal or metatarsal joints
How do you diagnose rheumatoid arthritis?
Anti cyclic citrullinated peptide antibody (anti CCP) is the most SPECIFIC test for rheumatoid arthritis.
- If you have CCP+, you likely have RA
Investigations for rheumatoid arthritis
- Rheumatoid factor – positive in many patients, but not as specific.
- anti CCP = positive in RA
- ESR and/or CRP increased (inflammatory joint disease)
- ANA titre positive in some patients
- Xray findings: Erosions of bone
Define osteoporosis
- Thinning/weakening of the bones putting patients at risk for fractures.
- Mild thinning is called Osteopenia. Severe thinning is called osteoporosis.
Symptoms:
• ASYMPTOMATIC UNTIL A FRACTURE APPEARS. Osteoporosis
Risk Factors for osteoporosis
- post-menopausal women
- increasing age
- smoking
- steroid use
- low BMI
Symptoms of osteoporosis
ASYMPTOMATIC UNTIL A FRACTURE APPEARS.
Diagnosis of osteoporosis
Diagnostic: DEXA scan
- Look at the T score on a DEXA scan.
T score = 0, normal bone density. Your bones are as strong as people your sex/age
- T score >0, good bone density. Your bones are stronger than people your age/sex
- T score between -2.5 and 0, osteopenia
- T score > -2.5 = osteoporosis
Define Pagets disease
Disease of increased but uncontrolled bone turnover.
- It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.
clinical features of paget’s disease
Symptoms: only 5% are symptomatic
1. older male with bone pain and an isolated raised ALP
- bone pain (e.g. pelvis, lumbar spine, femur)
- classical, untreated features: bowing of tibia, bossing of skull
- raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
- other markers of bone turnover include: procollagen type I N-terminal propeptide (PINP), serum C-telopeptide (CTx), urinary N-telopeptide (NTx), and urinary hydroxyproline
Investigation for Paget’s disease
- Bloods:
- raised alkaline phosphatase (ALP)
- calcium* and phosphate are typically normal - other markers of bone turnover include:
- procollagen type I N-terminal propeptide (PINP)
- serum C-telopeptide (CTx)
- urinary N-telopeptide (NTx)
- urinary hydroxyproline - skull x-ray
- thickened vault, osteoporosis circumscripta
Renal bone disease: basic problems in CKD
- Low vitamin D (1-alpha hydroxylation normally occurs in the kidneys)
- high phosphate
- low calcium: due to lack of vitamin D, high phosphate
- secondary hyperparathyroidism: due to low calcium, high phosphate and low vitamin D
Clinical manifestations of renal bone disease
- Osteitis fibrosa cystica
aka hyperparathyroid bone disease - Adynamic
- reduction in cellular activity (both osteoblasts and osteoclasts) in bone
- may be due to over treatment with vitamin D - Osteomalacia
- due to low vitamin D - Osteosclerosis
- Osteoporosis
Complication of vitamin D deficiency
Osteomalacia – softening of the bones secondary to low vitamin D levels
- In turn leads to decreased bone mineral content
Symptoms of vitamin D deficiency
- Bone pain
- Bone/muscle tenderness
Investigations for vitamin D deficiency
Diagnostics:
- Bloods – low vitamin D, calcium, phosphate
- Raised ALP - X-Ray – translucent bands
What is metabolic bone disease?
Disorders of bone strength usually caused by abnormalities of minerals (such as calcium or phosphorus), vitamin D, bone mass or bone structure
What is Reiter’s syndrome also known as? 2B
reactive arthritis
Define reactive arthritis 2B
an arthritis that develops following an infection where the organism cannot be recovered from the joint.
Classic presentation of reactive arthritis 2B
‘Can’t see, pee or climb a tree’
Features of reactive arthritis 2B
- Time course
- typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months - arthritis is typically an asymmetrical oligoarthritis of lower limbs
- dactylitis
- symptoms of urethritis
- eye
- conjunctivitis
- anterior uveitis - skin
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What is Polyarteritis nodosa (PAN)? 2B
vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation.
Features of Polyarteritis nodosa (PAN) 2B
- fever, malaise, arthralgia
- weight loss
- hypertension
- mononeuritis multiplex, sensorimotor polyneuropathy
- testicular pain
- haematuria, renal failure
- perinuclear-antineutrophil cytoplasmic antibodies (ANCA)
What is polymyositis? 2B
- inflammatory disorder causing symmetrical, proximal muscle weakness
- thought to be a T-cell mediated cytotoxic process directed against muscle fibres
- associated with malignancy
Features of polymyositis (2B)
- proximal muscle weakness
- +/- tenderness
- Raynaud’s
- respiratory muscle weakness
- interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia
- dysphagia, dysphonia
Investigations for polymyositis (2B)
- elevated creatine kinase
- other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT)
- EMG
- muscle biopsy
- anti-synthetase antibodies
What is scleroderma? (2B)
uncommon condition that results in hard, thickened areas of skin
- sometimes problems with internal organs and blood vessels.
Features of scleroderma (2B)
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linea
What is Sjogren’s syndrome?
2B
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
Features of Sjogren’s syndrome
2B
- dry eyes: keratoconjunctivitis sicca
- dry mouth
- vaginal dryness
- arthralgia
- Raynaud’s, myalgia
- sensory polyneuropathy
- recurrent episodes of parotitis
- renal tubular acidosis
Investigation for Sjogren’s syndrome
2B
- rheumatoid factor (RF) positive in nearly 50% of patients
- ANA positive in 70%
- anti-Ro (SSA) antibodies in 70% of patients with PSS
What is Juvenile idiopathic arthritis? (2B)
arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks
- Systemic onset JIA is a type of JIA
Features of systemic onset JIA
2B
- pyrexia
- salmon-pink rash
- lymphadenopathy
- arthritis
- uveitis
- anorexia and weight loss
Investigations for Juvenile idiopathic arthritis (2B)
- ANA may be positive,
2. rheumatoid factor is usually negative
What is Systemic lupus erythematosus (SLE)? (2B)
A chronic multi-system autoimmune disorder
- most commonly affects women during their reproductive years
- can affect any body system
Features of SLE (2B)
General
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
Skin:
- malar (butterfly) rash: spares nasolabial folds
- discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas.
- photosensitivity
- Raynaud’s phenomenon
- non-scarring alopecia
MSK:
- arthralgia
- non-erosive arthritis
Cardiovascular
- pericarditis: the most common cardiac manifestation
- myocarditis
Respiratory
- pleurisy
- fibrosing alveolitis
Renal
- proteinuria
- glomerulonephritis
Neuropsychiatric
- anxiety and depression
- psychosis
- seizures
Investigations for SLE (2B)
Antibodies:
- ANA positive
- –>This means if you someone has a negative ANA, they do not likely have lupus. If someone has a positive ANA, use clinical judgement. IS NOT DIAGNOSED FOR SLE - dsDNA+
- Less sensitive but more specific for SLE than ANA
- Rarely found in healthy patients
- Generally diagnostic for SLE - Complements (C3 and C4)
- used to track disease activity. Low complements (low C3 and C4) suggest higher disease activity - Anti-Sm (Anti smith) – very specific for SLE
What is Slipped Upper Femoral Epiphysis?
Displacement of the femoral head epiphysis postero-inferiorly
Risk Factors for Slipped Upper Femoral Epiphysis
- typically age group is 10-17 years
- More common in obese children and boys
- Males > Females
Features of Slipped Upper Femoral Epiphysis
- hip, groin, medial thigh or knee pain
- Limp with leg externally rotated,
- loss of internal rotation of the leg in flexion
- restricted range of motion (ROM) on exam
Investigations for Slipped Upper Femoral Epiphysis
- AP and lateral (typically frog-leg) views are diagnostic
2. AP xrays of bilateral hips and frog-leg lateral
Femoral neck fracture
Classically: Elderly woman with osteoporosis, minimal injury.
Symptoms of Femoral neck fracture
- Pain in groin and unable to bear weight
- leg may be shortened, externally rotated, and abducted.
Hip Dislocation
- 90% are posterior; Example: Dashboard injury
- Compared to femoral neck fracture, MAJOR injury/high impact/trauma, any age
Symptoms of Hip Dislocation
- Pain, inability to bear weight
- deformity (hip and leg in slight flexion, adduction, and internal rotation)
- leg shorter
Investigation for Hip Dislocation
Diagnostic: X-Ray
What is septic arthritis?
Spread of bacteraemia, periarticular osteomyelitis, infection due to diagnostic or therapeutic procedure or from infection elsewhere
- Involves single joint
- Commonly knee, hip, shoulder, ankle, wrist
Features of septic arthritis
- Joint is hot, acute swelling, tender, restricted ROM
- Effusion, tenderness to palpation, increased pain, minimal ROM
- fever
Investigation for septic arthritis
Diagnostics – Aspirate native joint for culture and gram stain before starting antibiotics
–> *Pearl: Never aspirate a prosthetic joint. Refer to ortho specialist!
What is acute osteomyelitis?
inflammatory condition of bone caused by an infecting organism
- It usually involves a single bone
Most common cause of osteomyelitis
Staphylococcus aureus.
Symptoms of osteomyelitis
- Non-specific pain
- fever
- malaise/fatigue
- inflammation
- swelling
Investigations for osteomyelitis
- WBC (inc), CRP&ESR (inc), - xray – osteopenia & bone destruction
- MRI – imaging of choice
Complication of chronic osteomyelitis
sequestra- dead bone after few weeks
Osteosarcoma
most common primary malignant bone tumour
- seen mainly in children and adolescents
X-ray finding of osteosarcoma
- Codman triangle (from periosteal elevation) and ‘sunburst’ pattern
Specific test for Rheumatoid arthritis
RF - positive
CCP - Most specific
ANA - low positive
ESR/CRP - often elevated
Specific test for SLE
dsDNA & anti Sm - positive, very specific
RF - often positive
CCP - negative
ANA - low positive
ESR/CRP - often elevated
C3/C4 - often low
Specific test for Sjogren’s Syndrome
anti-Ro (SSA)/anti-La (SSB) - positive, very specific
RF - often positive
CCP - negative
ESR/CRP - often elevated
Specific test for Myositis
CK - increased
Anti Jo-1 - positive
ANA - often positive
ESR/CRP - often elevated
Specific test for Scleroderma (limited)
ANA - positive
Anti-centromere - positive
Anti-Scl 70 - negative
ESR/CRP - often elevated
Specific test for Scleroderma (diffuse)
ANA - positive
Anti-centromere - negative
Anti-Scl 70 - positive
ESR/CRP - often elevated
Specific test results in normal patients
RF - possibly positive
CCP - negative
dsDNA & anti Sm - negative
ANA - possibly positive
ESR/CRP - typically normal
What is adhesive capsulitis commonly known as
frozen shoulder
epidemiology of adhesive capsulitis
middle-aged females
medical condition associated with adhesive capsulitis
diabetes mellitus
onset of adhesive capsulitis
develops over days
examination sign of adhesive capsulitis
external rotation affected more than internal rotation or abduction
how long do episodes of adhesive capsulitis last
6 months to 2 years
how is diagnosis of adhesive capsulitis made
clinical though imaging may be use if sx persist
Name the rotator cuff muscles
SIts
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Which rotator cuff muscle is most commonly injured
supraspinatus
Sx of rotator cuff injury
shoulder pain worse on abduction
Clinical sign of rotator cuff injury
positive painful arc
60-120 degrees - subacromial impingement
<60 degrees - rotator cuff tear
What is a subluxation
partial dislocation
Which investigation is required in subluxation?
xray to confirm
What should be checked before and after reducing a dislocation?
neurovascular status
Examination findings of rotator cuff injuries
Supraspinatus - empty can test & pain on resisted abduction
Infraspinatus (pain on resisted lateral rotation)
Subscapularis (pain on resisted medial rotation).
Are shoulder dislocations usually anterior or posterior
98% anterior - classically after FOOSH
Lateral epicondylitis cause
tennis elbow - overuse of epicondyle in activities like playing tennis/house painting
sign and sx of Lateral epicondylitis
- localised pain and tenderness
- pain worse on resisted wrist extension with elbow extended
Medial Epicondylitis
golfers elbow - overuse of flexor/pronators
sx of Medial Epicondylitis
pain from the elbow to the wrist on the inside (medial side) of the elbow
point tenderness
Which type of fall typically leads of a Colles fracture
FOOSH
What is a colles fracture
Distal radius fracture with dorsal displacement of fragments
characteristic sign of colles fracture
dinner fork deformity
Colles fracture mnemonic!
Dorsally Displaced Distal radius → Dinner fork Deformity
s/s of pulled elbow
- not using arm
- elbow in extension & forearm in pronation
- pain with supination of forearm
Smiths vs Colles
Smiths - ventral displacement (reverse colles)
Colles - dorsal displacement
Sx of scaphoid fracture
pain at base of thumb / radial aspect of wrist
loss of grip/pinch strength
What is the danger of missing a scaphoid fracture?
avascular necrosis caused by interrupted blood supply
Pain in anatomical snuffbox and normal xray -> next step?
IMMOBILISE IF ANY DOUBT
Definitive investigation to confirm or exclude diagnosis of scaphoid fracture
MRI (check)
What is carpal tunnel syndrome
compression of median nerve in carpal tunnel
sx of carpal tunnel syndrome
- pain and pins and needles in thumb, index, middle finger
- relieved by shaking hand / hanging hand off bed
- worse at night
clinical examination findings of carpal tunnel syndrome
- weakness of thumb abduction
- thenar eminence wasting
- positive Tinels and Phalens
Diagnostic investigation of carpal tunnel syndrome
Nerve conduction studies
What is de Quervain’s tenosynovitis?
the sheath
of the tendons on the thumb side of the
wrist becomes inflamed or swollen,
restricting the tendons’ movement
s/s of de Quervain’s tenosynovitis
pain with turning wrist
+ finkelsteins
Boxer’s fracture
Fracture of 5th Metatarsal
usually after punching something
Back pain red flags!
- suspected spinal infection
- saddle anaesthesia
- loss of anal sphincter tone
- bowel/bladder incontinence or urinary retentions
- motor/sensory deficit
Back pain investigation
none needed if no red flags
MRI
How to differentiate mechanical vs inflammatory back pain
MECHANICAL
- worse on movement
- cause is injury
- fluctuating sx
INFLAMMATORY
- morning stiffness >1hr
- better with movement
- insidious onset
- progressive
- younger pt
Kyphosis
> 45 degree curvature of the spine that causes the top of the back to appear more rounded than normal
Scoliosis
twisting and curving of the spine
Hernated nucleus pulposus
pain in leg due to compression of spinal nerve
sx of Hernated nucleus pulposus
- Unilateral
- leg pain worse than low back pain
- pain worse when sitting
- pain radiates to foot or toes
- numbness and paraesthesia
diagnostic investigation of Hernated nucleus pulposus
MRI
Which nerve roots are affected if pain radiates from back to hip and/or anterior thigh
L1-L3
Which nerve roots are affected if pain radiates from back to below the knee
L4-S1
spinal stenosis
Narrowing of spinal canal
complications of spinal stenosis
root compression and ischaemia
sx of spinal stenosis
- insidious back pain
- paraesthesia with movement, relievd by lying supine
- bilateral leg pain, relieved by leaning forward
- numbness in lower extremity
Which nerves are compressed in cauda equina
L1-S5
Sx of CES
- Saddle (perianal/perineal) anaesthesia
- bladder dysfunction
- faecal incontinence
- neurological deficit
Ankylosing Spondylitis
Chronic inflammatory joint disease of spine
Affecting spine and sacroilliac joints
epidemiology of ankylosing Spondylitis
caucasian males - mean onset 26yo
classic vignette of ankylosing spondylitis
insidious onset, morning stiffness, young man, with a
family history and pain relieved by exercise
clinical examination findings of ankylosing Spondylitis
- reduced lateral flexion
- reduced forward flexion
- reduced chest expansion
which genetic component is associated with Ankylosing Spondylitis
HLA-B27
Classic xray finding of Ankylosing Spondylitis
bamboo spine
Osgood schlatter epidemiology
teenagers 10-14yo
What is osgood schlatter a type of
osetochondritis - joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow
cause of Osgood schlatter
excessive muscle pull on growing bone (growing pains)
epidemiology of Osgood schlatter
active young people,
commonly footballers
s/s Osgood schlatter
Pain and swelling directly over the tibial tubercle
Point tenderness
Pain is aggravated by loaded knee extension activity
Bursitis
inflammation of a bursa
s/s bursitis
- localized swelling and erythema overlying the patella
- difficulty kneeling/walking
investigations for bursitis
- aspiration
- xray
- bloods
What is bursal aspiration used to rule out?
septic bursitis or crystal-induced bursitis
Investigation for meniscal injury
MRI
special tests - meniscal injury
McMurray and Apley
Cause of meniscal injury
twisting injury while weight bearing
sx of meniscal injury
- catching/locking of knee joint
- pain in knee joint
- swelling
What causes the knee pain in meniscal injury
if a meniscus is torn the torn fragment can
be trapped in the joint and cause
transient locking/catching, which often
causes severe pain knee
Chondromalacia patella
loss of cartilage underneath the patella
What aggravates knee pain in Chondromalacia patella
deep bending
clinical signs of Chondromalacia patella
hypermobile patella with significant crepitus
What is seen on an xray in Chondromalacia patella
skyline view show ”bone on bone” patella and femur
